Obamacare: Doctor, hospital participation in exchange health plans still being determined

As the state’s new insurance marketplace prepares to begin selling coverage in less than two weeks, officials are still waiting to find out which doctors, hospitals and other health care providers will accept the health plans being offered.

Besides price, the lists of doctors and hospitals that take each insurance plan will be among the only differences between the insurance plans offered to customers of the new marketplace -- those who are uninsured, who buy coverage on their own, or who work for small employers.

Chad Brooker, chief exchange policy and legal analyst for Access Health CT, the new marketplace, said the insurance companies consider the provider lists proprietary and haven’t shared them. But the information is expected to be available in searchable form by Oct. 1, when customers will be able to shop for health plans through Access Health.

Access Health, the state’s health insurance exchange, which was created by the federal health reform law, requires that the insurers’ networks be substantially equal to the networks used for their largest commercial plans.

“We know that there are going to be some differences,” Brooker said. “It’s the degree of the differences that’s the real key.”

Some insurers are still negotiating with health care providers considering joining their networks. In some cases, hospital officials have been reluctant to participate in plans that are part of a new marketplace with many unknowns, while some carriers want providers to accept payment rates that are lower than what they typically get from private insurance, people involved in negotiations say.

Network size has been an issue in other states. In California, for example, Blue Shield of California’s exchange network is about half its regular physician network, the Los Angeles Times reported.

Some hospitals in, some out

Three insurance companies will sell plans through Access Health’s individual market: Anthem Blue Cross and Blue Shield, ConnectiCare and HealthyCT, a new nonprofit insurer. Anthem and HealthyCT will also sell insurance through Access Health’s small-group market, as will UnitedHealthcare.

Some hospitals will accept insurance from all the exchange plans, including those in the Yale New Haven Health System -- Yale-New Haven, Bridgeport and Greenwich hospitals.

Others won’t. St. Francis Hospital and Medical Center, for example, decided to sign up with ConnectiCare and HealthyCT, but won’t be part of the Anthem or UnitedHealthcare exchange networks.

Access Health CEO Kevin Counihan said he doesn’t think carriers will have a problem meeting the provider network requirements. “From what we’re hearing, I don’t think that’s going to be an issue,” he said.

HealthyCT CEO Kenneth Lalime said he expects that 75 percent of the state’s hospitals will be participating in the company’s network by the end of the month, and hopes all will have signed on by Jan. 1, when the coverage takes effect. “We are definitely still in the continuing-to-develop stage,” he said.

Hospitals worried about the unknowns

Lalime said getting hospitals to participate has been a bigger challenge than getting doctors on board. Some hospital administrators are “a little leery of the current marketplace,” he said.

“Some have come forward and said we’re just not real comfortable with what is going on with potential members coming from the exchange business and all the rest,” he said.

Their concerns include not knowing who the customers will be and whether they’ll have significant unmet medical needs, as well as concerns that some patients will have high deductibles requiring them to pay out-of-pocket for care.

Getting doctors to sign up has been easier, Lalime said. About 5,000 will be part of HealthyCT’s network, and Lalime predicted that more will join as the company reaches agreements with hospitals.

“We believe that it will be an adequate network to support the membership at any point in time that somebody signs up,” he said.

In a statement, Anthem said the provider networks for its exchange plans will meet the requirements. “We have been successful in securing provider participation in our small group and individual exchange networks and we will have substantially similar networks for our on and off exchange plans,” the statement said.

ConnectiCare is still negotiating with providers and declined to comment on its network. A UnitedHealthcare spokesman did not respond to a request for comment.

Comparison shopping

Each insurer offering coverage through Access Health must sell plans with a set of standard benefits and cost-sharing requirements, allowing customers to compare equivalent plans by price and providers covered. Insurers can also offer additional plans with different features.

“People are going to, number 1, choose on price,” said Jess Kupec, president and CEO of St. Francis Health Care Partners. “I don’t think there’s anybody I’ve talked to anywhere in the country that doesn’t say price drives selection. If you have the right price, which is the lowest price from the consumer perspective, and your provider is in the network you’re in, decision made.”

People in good health are more likely to choose a plan with a better price, even if it requires them to switch doctors, Kupec said. By contrast, people with health problems who’ve built relationships with their providers are less likely to want to change.

In deciding which exchange insurance plans to accept, Kupec said, St. Francis’ strategy was to be conservative and determine which plans would have the best chance to succeed.

Another reason for limiting participation, Kupec said, are the unknowns associated with taking part in a new market.

“We want the exchanges to be a success. We want those who don’t have insurance to get insurance and to seek care and to really focus on preventive services,” he said. “On the other hand, it’s a little unclear right now exactly how this is going to really roll out come Oct. 1.”

St. Francis chose to participate with local companies -- ConnectiCare and HealthyCT. It won’t take the Anthem or UnitedHealthcare plans sold by Access Health.

Kupec said national insurers appeared to have a one-size strategy across the country, tying reimbursement rates to Medicare rates. That might work in places where Medicare rates are high, but not in places where they’re low.

The payment rates St. Francis will be getting for exchange insurance is somewhere in the middle between existing private insurance plans, which tend to pay the most, and Medicaid, the lowest payer, Kupec said.

Hartford HealthCare, the parent company of Hartford, Windham and Backus hospitals, The Hospital of Central Connecticut, and MidState Medical Center, has committed to participating in the exchange with some insurers and is waiting to see final details from others, said James Cardon, the company’s chief clinical integration officer. He declined to say which exchange insurance plans the hospital network would accept.

Lower rates for doctors

Dr. Stephen Salzer, a Greenwich otolaryngologist who is on the HealthyCT board, said insurance companies have offered lower rates for doctors participating in their exchange networks than for their regular commercial plans.

“It’s definitely clear the fees are going to be less,” he said, adding that a lot of doctors he knows won’t participate with commercial insurers seeking lower fees.

HealthyCT is an exception, he said. The company is offering to pay doctors the same rates for plans sold in and outside the exchange.

Patient advocates say it’s important to measure not just the total number of providers participating in each insurer’s exchange network, but whether they’re accepting new patients and whether their patients can get appointments.

Although Access Health probably won’t have a chance to review the networks before the plans go on sale to the public Oct. 1, Brooker said staff will begin analyzing them when the marketplace launches, which will leave three months before the coverage takes effect. The exchange can’t levy fines for not complying with the requirements. It could keep carriers from participating in the exchange, but Brooker called that the “atomic option.”

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